Category: exercise

Someone asked me to wrote more about carotid artery disease, so here goes. We see a large number of patients with carotid artery stenosis. Next to aneurysms, I don’t think that there is any other medical condition that raises more anxious feelings for patients. The paired carotid arteries supply the left and right side of the brain. There are ale smaller arteries that supply the back of the brain named the vertebral arteries, and there is a communication between the 2 systems within the brain called the Circle of Willis. But the dominant supply to each side of the brain is via the carotid artery. Blockages in the carotid artery can lead to strokes. The typical symptom of a stroke are loss of motor control on one side of the body versus the other, loss of speech ability, and loss of vision in one eye versus the other. Stroke symptoms do not cause pain, and vague symptoms such as dizziness and vertigo are not typical of strokes (unless it occurs in a certain area of the brain that control balance).

The typical risk factors for carotid artery disease are the same as for other cardiovascular diseases, namely cigarette smoking, high blood pressure, high blood sugar, high cholesterol, age and family history. Age and family history you are stuck with. If Dad or Mom had heart disease and strokes at an early age, then unfortunately you are probably at a higher risk. But the other risk factors are able to be controlled with medication if needed, or diet and exercise and smoking cession.

Most people with carotid artery disease never have symptoms. In general, the higher the degree of narrowing, the greater the risk of symptoms. Sometimes, you can have what is called a Transient Ischemic Attack (TIA) or mini-stroke, and at other times you might have a full blown stroke. The difference between the two is that a TIA resolves within 24 hours, while a stroke last greater than 24 hours. We don’t know which event is going to occur, if it does occur. We just know if you have a TIA, and you have significant carotid artery narrowing, your risk for a full blown stroke is a lot higher.

Most patients with carotid artery stenosis do not need surgery. We emphasize controlling the risk factors, as well as smoking cessation. I advocate an anti-platelet agent such as Plavix or aspirin, and close follow-up. We used to be much more aggressive with carotid stenosis in terms of surgical management years ago. However, in the era of anti-platelet agents such as Plavix, as well as statin drugs to control cholesterol level, and much better management of diabetic patients by our family practice and medical colleagues, the role for carotid artery intervention has diminished. The options for management of carotid stenosis include carotid surgery where the blockage is cleaned out versus carotid artery stenting where the blockage is essentially reopened with a stent. There is an ongoing debate about which technique is better for patients. I suspect the answer is going to be dependent on the patients age, and anatomy, as well as other cardiovascular issues such as heart disease.

I dont think there is any doubt that if you have a TIA or a stroke with good recovery, and you have severe carotid artery narrowing on the side of the stroke, that you would benefit from carotid artery intervention to reduce further strokes. What is less settled to me in the modern era is what should be done for patients with moderate to severe carotid artery disease (greater than 60% narrowing) who do not have symptoms of TIA’s or strokes. There are carotid stents or carotid surgeries being performed for that condition (so called asymptomatic carotid stenosis), but the data is not clear in my mind of the benefits of the intervention versus the risks. Thats what this whole business is about, balancing the risks versus benefits of every intervention we do.

I was trained the same way most physicians are trained in nutrition, and I suspect the same way that most other people in the health care industry are indoctrinated. For years, I thought the equation for weight was simple. Input equals output. If your input in terms of calories are greater than your output, then you gain weight. If your output was greater than your input, you lost weight. Simple. I recited the food pyramid to my patients diligently, and suspected that most people who thought they were following the correct diet and who did not lose weight were really not as strict as they thought. If they only counted calories, they would lose weight. I was the typical 35% cards, 35% protein, 30% fat diet guy. When I started to hack my own diet and exercise, I discovered that at least for me, what I had been taught was all wrong. Now I eat at least 50% of my calories from fat, and approximately 30-35% protein, with the rest being carbs. I don’t eat bread or pasta. I eat sweet potatoes only on a leg or back workout day (large muscle groups). I have lost body fat, my waist size is less than 30 inches, and I am 56 years old (soon to be 57). Turns out there is new science validating some of this information. As we get older, the body does not like to let go of fat. You have to trick it into thinking there is lots of fat around. It really works. If you are a male in your 40’s or older, change the way you eat. Combine it with variations of high intensity interval training. You will feel better, and you will lose the body fat. I should add I suspect the situation is more complex for women.

The carotid arteries are the main blood supply to most of the brain. The right carotid artery supplies the right side of the brain. A right sided stroke symptom will include loss of vision in the right eye, kid of like those old movie theaters where a curtain comes down over part of the eye or all of it. This event is called Amaurosis Fugax. Another potential symptom of a right brain stroke is loss of motor control of the left side of your body. You may be stirring a cup of coffee with your left hand, and all of a sudden you can lift your hand. There is no pain associated with these events. A left brain stroke will cause the opposite event to the right side, namely amaurosis fugax of the left eye and loss of right sided motor control. In addition, most peoples speech centers are on the left side of the brain, so you may lose your ability to speak even though you know what you want to say, or it may come out as a string of non-sense words.

Carotid artery blockages are one of the many potential reasons for a stroke. The risk factors for carotid artery disease are the same as the risk factors for other cardiovascular diseases. These include 1. Cigarette smoking

2. Diabetes

3. High blood pressure

4. High cholesterol or triglycerides

5. Age

6. Family history of circulation problems

Most people with carotid artery narrowing do not know they have it. If you have had a heart attack or has peripheral vascular disease, then you have a higher risk for carotid artery narrowing. Most patients with carotid artery stenosis do not need surgery. Age and family history you are stuck with! Our goal is to prevent the narrowing becoming worse but making sure that your blood pressure, blood sugars, and cholesterol levels are well controlled, and that you stop smoking.

If you have been diagnosed as having carotid artery narrowing, the prognosis is really quite good. Most people will never need their carotid artery repaired. Th old standard for treatment of carotid artery narrowing that was 60% or greater was surgical intervention based on a study published in the New England Journal of Medicine. However, this study was prior to the current era where we have Plavix which is like a super aspirin, and statin drugs. Therefore, the management of carotid artery disease has changed somewhat to a more conservative approach, as outlined by the writings of Dr. Frank Veith, one of the most thoughtful and smart vascular surgeons who has been around a long time and seen it all. I personally discuss surgery in patients who have had a TIA or ministroke and carotid artery narrowing on the side of the TIA. A TIA is a stroke like symptom, but by definition, you recover function within 24 hours. If you have a TIA, and have severe carotid artery narrowing on the side that caused the TIA, then you have a high risk for a full blown stroke, and really should have intervention for the carotid artery narrowing.

In terms of treatment for carotid artery stenosis, as I mentioned most people do not need intervention, and can be managed with anti-platelet agents that thin out the blood such as aspirin or Plavix, as well as control of their cardiovascular risk factors, statin drugs as necessary, and smoking cessation. Why not fix all carotid artery narrowing when it’s present? Because the intervention itself carries a risk for stroke and even heart problems. This business is all about balancing the risks versus benefits of everything we do. If the risk of stroke is low with carotid artery narrowing, then it is better managed conservatively. If intervention is required, the options are to either have a surgical intervention or a carotid artery stent. There are advantages and disadvantages of both. I personally do not do carotid artery stenting; I think that is better left to someone who has experience in doing the procedure, but also in fixing problems that may arise both during and after the procedure. If I think a patient is better served by a carotid artery stent rather than surgery, I will ask them to see a friend of mine who is a neurointerventional radiologist, basically a specialist in all things related to the blood flow to the brain. He might come back and tell me “no, I think this case would be better served by surgery, or yes I think carotid artery stenting would be a good option.” Remember the old adage “if your only tool is a hammer, the whole world looks like a nail.”

Monday was my leg day, and after testing the out limits of my quadriceps weight bearing abilities, the last thing I wanted to do was to get on the stair stepper or treadmill and run. So I experimented with the incline and speed on the treadmill. I took my baseline heart both with a stop watch and the machine and it correlated well at around 68 beats per minutes (bpm). Then I started off at 3 degrees incline and at 2.5 miles per hour (mph) on the treadmill. With each change in the variables, I correlated the machine readout of my heart rate with my stopwatch, and they were actually quite comparable. I increased my incline sequentially by a few degrees, and increased my walking rate to 3 mph. at 15 degrees incline and 3 mph, my heart rate was persistently in the 130+ range. At 10 degrees, it was in the 120 range. So I varied the incline every 2-3 minutes, and kept the speed at a comfortable constant 3 mph for 40 minutes. At the end, my legs did not hurt, and I had a good cardio workout. It also did not seem as onerous as pushing myself hard on the treadmill or stair stepper for 30 minutes, and I achieved the same calculated calorie goal. For those who say that they don’t have 40 minutes to do this type of experiment, you can split it up into 2 20 minute sessions, one in the morning and the second at night. In fact, there is research that suggests splitting up cardio into 2 shorter sessions rather than 1 long session boosts your metabolic rate higher than just one session.

So sometimes I get out of work, and my legs just don’t want to cooperate in terms of running or doing significant cardiovascular work. So how to get my cardio in and keep my heart rate above 130 for one minute intervals at least 10 times? I find that if I try and grind it out by running fast on days like this, I get discouraged. Its not my heart rate and shortness of breath withe exercise that limits my running on days tike this, it my legs that just feel tight and fatigued. For example, every Tuesday I am in the clinic all day, on my feet seeing patients. I have been in practice for 25 years, and I see 50-60 patients on Tuesday. So my hack is when I get on the treadmill, I get my heart rate up by running slower on a steep incline, say 5-8 degrees at 4 mph. I usually cycle every 2 minutes, meaning I run at 4 mph at 8 degrees incline, then 4 mph at 1 degree for 2 minutes. I repeat this cycle for 40 minutes, and get a nice work-out. I vary the incline on how I feel. Usually, I will start off at 5 degrees incline, but as I run longer and feel better, I increase the incline on my higher intensity segments. Try it, it really does work.

I unfortunately have to agree that deadlifting is probably the most bang for the buck weight lifting maneuver. As much as I don’t like doing it, the move really improves my core and strengthens my upper body. As with most other type A personalities, I get addicted to the exercise easily, and try and pack on more weight in order to outdo myself. I think that why I tore my rotator cuff on the incline dumbbell press. So I try to think like a mature 56 year old and do reasonable weights. I learned a lot from listening to Pavel Tsatsouline, the chairman of StrongFirst. Pavel apparently introduced the west to the kettle bell training program. A few tricks I learned from him include gripping the bar really hard helps recruit muscles during a lift. Also concentrating on tightening the core muscles just prior to the actual lift seems to make the effort easier. He also mentions that the Russian powerlifters usually stick to 6 reps in order to build mass. There are a ton of videos on Youtube on deadlifting technique by Mark Rippetoe, Dan John, and Ed Coen. The one I think that is most informative for us normal sized folks is at the link by Mark Rippetoe.

I used to think that weight control was just an issue of calories in versus calories out. Now I have to face the fact that what I was taught many years ago, and spouted off with regularity may not be exactly correct. I know from my own personal body hacks that the old paradigm of low fat diet did not work, especially after age 50. I actually eat much more fat in my daily diet. My morning starts of with 2 cups of coffee with a single teaspoon of brown sugar, and a spoonful of MCT oil. I then drink a 42 g Myoplex EAS protein shake (Chocolate of course!) in between seeing patients. A couple of spoonfuls of natural peanut butter helps. I also eat 2 handfuls of pistachios, and well as 2 handfuls of almonds. For lunch, I have protein such as chicken breast and salad. I have a mid-afternoon snack of greek yoghurt, and then hit the gym. I usually lift weights for 50-60 minutes, but I don’t take more than a 3-5 minute break between sets. I then do 30-40 minutes of cardio, either treadmill or stair stepper. I try and do high intensity intervals if at all possible, but sometimes my body just is too tired, so i just try and be persistent and complete 40 minutes of some type of cardio with a minimal heart rate of 100. As I am finishing my weight lifting part, I take 25 grams of cold ultra filtered whey protein, 25 grams of casein, and 5 grams of creatine in about 12 – 16 ounces of water. I learned a lot by researching proteins before I made my purchase. A good general rule of thumb is look at the ingredients on the side of the protein package. If it is high in cholesterol (greater than 10-20 mg per serving), it is not a good quality protein. Then I have dinner, usually protein and vegetables. By sticking to this regimen, my waist size is 30, and my body fat is the lowest it has ben since I was a teenager. By the way, interesting factoid that most people don’t know. Waist size of 40 inches or greater in men an 35 or greater in women is an independent risk factor for cardiovascular disease. In plan English, this means that even if you are not diabetic or have high blood pressure, you are at an increased risk for heart attacks and strokes if your waist size is greater than 40 inches or 35 inches in a male or female, respectively.

My epiphany moment was 7 years ago at age 49 when I woke up at 5 am as I had done for many years, got out of bed and thought to myself “why do I feel like crap?” I have lifted weight since I was 18 years old and have always done regular cardiovascular activity. As a physician, I knew a good bit about nutrition, and felt that I was following a good diet. I ate a low fat diet, balanced carbs and proteins. My paradigm was the old input equals output equation, which I quoted to my overweight patients. But despite what I thought was the correct way of eating and exercising, I realized at age 49 that I did not feel good. I went to Las Vegas to the Cenegenics Institute for anti-aging, was evaluated, and actually took the course and was certified by them in anti-aging medicine. To be perfectly honest, I did not like the gist of the course. They pushed hormone replacement rather than trying to root out the cause of testosterone deficiency in a young male. That introduction led to years of hacking myself and my body with different ways of eating and exercising. I trained for a year with a professional bodybuilder, and got jacked up to 185 pounds on a 5’8” frame. I could barely fit into my lab coat. Then I tore all 4 of my rotator cuff muscles on my left arm doing incline dumbbell press with 80 pounds, and had to have a surgical repair 3 years ago. After years of trying different ways of eating and exercising, I realized that my old paradigm of a low fat diet, input versus output concept was just not correct. So now I eat a diet high in selected fats, and weight train and exercise with much more focus on the outcomes I want to achieve. The results have been nothing short of spectacular.

Ok in the middle of my third week. I have a few observations to report

My strength has diminished by approximately 10%. This may be related to just not getting enough calories in during the day

My leg recovery is very slow. I have a hard time with squatting more than a few reps without a “burn”. I suspect my thigh muscle glycogen level is at a minimum. I must investigate if big muscle groups like the thighs can adjust well to using ketones for energy production

I have not lost much weight, maybe 3-5 pounds max

I am sleeping extremely well, unless I wake up hungry like last night

Splitting cardio into 2 sessions really makes sense and is easier to do with 20 minutes in the am and 30 min in the pm

So I started on a ketogenic diet about a week ago, in order to reduce my body fat and get into better shape. Not that I am in horrible shape, but I wanted to experiment to see how it made me feel. Like most people, I get the fatigue symptoms after lunch, and generally have lost some of the high intensity energy I used to have. I guess part of that lack of energy could be from being 55 years old, and 8 year of college and medical school, 8 years of general and vascular surgery residency, and 24 years of clinical vascular surgery practice can do that to you! I have already learned a few things and some observations

MCT oil is palatable in coffee, but do not start of with a tablespoon of oil. It will most likely lead to diarrhea, and you won’t take it again! Start of at just a teaspoon, and slowly increase it over a week or two. I am now up to 3 teaspoons a day, and no problems

Take high quality proteins that are low in fat such as skinless chicken breast and salmon or tuna. I eat less red meat, mostly because its sometimes hard getting a lean cut of meat, and animal fat tends to be more saturated fats which is what I am trying to avoid

I am loving using more olive oil in cooking and salads

I really enjoy eating a handful of nuts daily, including almonds and peanuts

I dont feel guilty about snacking on a tablespoon natural peanut butter when I am hungry

Not sure about the bulletproof coffee concept will have to research that further but it seems like a large calorie dump from butter

I can definitely feel a difference within one week in terms of decreasing my body fat. I am going to keep a picture diary weekly to make sure that it is not an illusion

I also added a 20 minute cardio session in the morning. It is well known that splitting cardio into 2 sessions increases your metabolism over a 24 hour period better than doing all the cardio in one session. It also makes is easier time wise to split it up, and less strain on my body. I used to love running, but my orthopedist told me if i keep running, I may need knee surgery 10 years down the line, and that just seems like a hassle that I don’t want to get into. So I do about 20 minutes of elliptical work, getting my heart rate into the 130’s in the am. Sometimes I will do a shot run to break up the monotony. In the evening, I lift weight for 45 minutes, and then do 20-30 minutes of cardio, mixing it up between kettle bell swings, and the stair stepper machine.

The kettle bell is really much more difficult than I had imagined, and I think I am going to concentrate on learning more about it. It really gets my heart rate up, strengthens my core muscles, and there are many different exercises I can do with it